3. STEPS Have a system based approach Be focused Practice makes you perfect BLISS: Beginning, Listening, Information gathering, Sharing information, Setting goals.

5. GENERAL APPROACH Identify and Greet the patient Introduce yourself Understand the mood of the patient Be sensitive to the patient’s privacy and dignity Make him comfortable while taking history

6. COMMUNICATING WITH PATIENT Speak clearly and audibly Listen keenly with patience Do not jargon Do not use medical terms Avoid leading and direct questions Do not interrupt the patient

7. TAKING THE HISTORY AND RECORDING Always record personal details: –Name, –Age, –Sex, –Address, –Ethnicity, –Occupation, –Religion, –Marital status. –Record date of examination

8. ELEMENTS Presenting complaint History of presenting complaint Past medical history and risk factors Drug history and allergies Family history Social history Systemic or other system enquiry

9. PRESENTING COMPLAINTS Main reason to push the patient seeking a physician’s consultation Record the problem in the patient’s own words. Mention the duration of the illness Arrange the complaints in a chronological order in terms of duration.

10. PRESENTING COMPLAINTS IN CVS Chest pain (angina) Shortness of breath ( Dyspnoea) Giddiness (Syncope) Feel the heart beat or tap (Palpitation) Ankle swelling (Pedal edema) Cough (Claudication pain )

11. HISTORY OF PRESENTING COMPLAINTS (HPC) Elaborate on the chief complaints in detail Can use the medical terminologies Ask relevant associated symptoms Have differential diagnosis in mind

12. HPC - ANGINA Character of pain Onset and progression Site and radiation Aggravating and relieving factors Duration- getting worse? Associated features: SOB, sweating, nausea, palpitations

13. CCS GRADING OF ANGINA Class I: Angina only on strenuous or prolonged exertion Class II: Slight limitation due to angina with moderate exertion (walking uphill) Class III: Marked limitation due to angina with ordinary activity-walking level ground Class IV: Unable to undertake any physical activity, angina at rest.

14. HPC - DYSPNOEA Mode of Onset Progression (Grade) Duration Precipitating factors Relieving factors Associated features: Chest pain, palpitations, sweating, cough, haemoptysis

15. NYHA GRADING FOR DYSPNOEA Class I: Patients with cardiac disease but without dyspnoea during normal activities Class II: Cardiac disease resulting in mild/moderate dyspnoea on normal exertion Class III: Marked dyspnoea on ordinary exertion Class IV: Any exertion causes dyspnoea, or symptoms at rest

16. HPC - SYNCOPE Speed of onset Warning symptoms Precipitating events Nature of recovery period Associated symptoms (flushing, palpitation) Witness

17. HPC - PALPITATION Describe or tap out Precipitating and relieving factors Duration and frequency Associated features: SOB, chest pain, syncope

18. HPC – PEDAL EDEMA Onset and duration Site and extension Time of day Associated features: Pain in calf, SOB, chest pain, palpitations Lots of non-cardiac causes so need to extend HPC

19. A guide not to miss anything Any significant finding should be moved to HPC Do not forget to ask associated symptoms of PC with the system involved During verbal reports, do not comment on negative history on systems review to show you did it, however when writing up patient notes, record the systems review so that the relieving doctors know what system you covered. SYSTEMIC ENQUIRY

20. RS - cough, haemoptysis, wheeze GIT - appetite, weight, nausea, indigestion, bowel habit CNS - headache, weakness, sensory loss LM/skin - rash, joint pains GU - frothy/bloody urine, frequency, nocturia

21. PAST MEDICAL ILLNESS Ask for any major medical problems NB: IHD/Heart attack/ DM/ Asthma/HT/RHD/TB/Jaundice/Fits if so current medication and follow up Any operations done Any dental work up

22. DRUG HISTORY Any current medications NB: if so, mention with doses and frequency Any Previous thrombolysis Other drugs with CVS effects Any drug ALLERGIES

23. Any medical disease running in the family Cardiac diseases with a genetic component Family H/O DM, HT, PT, Asthma, allergy, stroke, & various genetic syndromes. FAMILY HISTORY

24. SOCIAL HISTORY Smoking history – amount in pack years, duration Alcohol history - amount, duration and type. Occupation Diet and others

25. COMPLETING THE HISTORY Ensure that you have got all the relevant information you need With the above, you should have an idea of likely diagnosis or atleast a differential diagnosis Your examination should elicit signs that will confirm or refute this.

26. Sample Clerking 16/12/05- Emergency admission under Medical Team seen by Dr X Mrs Anjana Siva 11/6/39 66 yr old Indian woman PC: Shortness of breath HPC: Gradual onset SOB starting 3 months ago Initially only on exertion but now SOB at rest Associated with: Orthopnoea, PND, Cough- frothy sputum, Ankle swelling, No palpitations, No chest pain Risk factors: Hypertension Family history of MI

27. Systems Review: GIT: Recent loss of appetite, no weight loss, no vomiting. No change in bowel habit. No abdominal pain. CNS:No abnormalities on questioning GUS: No abnormalities on questioning PMH: Hypertension- diagnosed 1 year ago given medications, doesn’t take them No previous history of ischaemic heart disease No diabetes/no stroke Cholecystectomy 1993- no complications DH: Bendrofluazide 2.5 mg od (pt doesn’t take it) Allergies:None known Family history: Father died aged 55- Myocardial infarction Mother died aged 70- Cancer of colon Social history: Never smoked Alcohol- 6 units/week Housewife, lives with husband (accountant) and 3 children

28. O/E Short of breath at rest No central or peripheral cyanosis Temperature 36.5 oC CVS: Pulse 90, regular BP 140/95 mmHg JVP + 6cm Thrusting apex- displaced to 6th ICS,ant. axillary line Pan-systolic murmur at apex- radiates to axilla HS Ankle oedema to knees RS: Respiratory rate 30/min Percussion and expansion normal Fine inspiratory basal crepitations in lower zones GIT: Soft, non tender 2cm hepatomegaly No palpable spleen or kidneys No shifting dullness CNS: No abnormalities detected on full neurological examination

29. Summary: Progressive dyspnoea in a 66 year old woman with a history of hypertension and clinical signs of pulmonary oedema, peripheral oedema and mitral regurgitation. Differential diagnosis: 1. Congestive cardiac failure secondary to ischaemic heart disease 2. Congestive cardiac failure secondary to mitral regurgitation 3. Congestive cardiac failure secondary to another cause Investigations: Blood tests: FBC, U+E, LFT ECG Chest X-Ray Echocardiography Treatment plan:Commence diuretics (frusemide 80mg bd) Fluid restriction 1.5 l/day Monitor urine output, weight and renal function Refer cardiology depending on ECG and echo findings Dr X MO in Medicine